The nurse is reviewing the patient's medical records which include history and physical, nurses' notes, imaging studies, and orders.

Exhibits

The nurse is asked to mark whether the assessment findings indicate that the treatment was effective or ineffective.

Which of the following options best describes the effectiveness of the treatment?

The treatment was effective.

The treatment was ineffective.

The treatment was partially effective.

It is too early to determine the effectiveness of the treatment.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.

PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.

Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.

Choice B rationale:

Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.

Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.

Choice C rationale:

The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.

Choice D rationale:

It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.

Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.

The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.

Choice B rationale:

Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.

Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.

The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.

Choice C rationale:

Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.

Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.

The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.

Choice D rationale:

IgE response hypersensitivity reactions are the most immediate type of allergic reaction.

They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.

When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.

These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.

The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.

A. Until a smaller angle can be restored. B. For long-term control of pain and swelling. C. Until the excess pressure is reduced. D. For long-term control of normal eye pressure.

Correct Answer is D

Explanation

Choice A rationale:

Incorrect. Open-angle glaucoma is not characterized by an abnormally small angle.

The angle in open-angle glaucoma is open, but the drainage system is not working properly. Therefore, restoring a smaller angle would not be an effective treatment goal.

Choice B rationale:

Incorrect. Eye drops used to treat open-angle glaucoma are not typically used for pain control.

While some individuals may experience mild discomfort associated with elevated eye pressure, pain is not a common symptom of open-angle glaucoma.

Additionally, eye drops used to treat glaucoma do not have anti-inflammatory properties to address swelling.

Choice C rationale:

Incorrect. While reducing excess eye pressure is an important initial goal of treatment, long-term management of open-angle glaucoma requires ongoing maintenance of normal eye pressure.

Simply reducing pressure temporarily is not sufficient to prevent vision loss.

Choice D rationale:

Correct. The primary goal of treatment for open-angle glaucoma is to maintain normal eye pressure over the long term. This is because elevated eye pressure can damage the optic nerve, leading to vision loss.

Eye drops are often used to lower eye pressure, and they typically need to be used for life to prevent vision loss.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

Correct Answer is D

Explanation

When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

The nurse notes that a patient has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

Patient Data shows that on Day 1, there were no active processes.On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side.What is the likely diagnosis?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?